Kathleen Wobie

Women and Children in Residential Treatment: Outcomes for Mothers and Their Infants

This paper examines the relationship between the living arrangement of mother and baby in a residential treatment center and measures of self-esteem, depression and parenting sense of competence and a womans length of stay and completion or non-completion of treatment. Scores on the Bayley Scales of Infant Development (Bayley 1969) are also examined by the amount of time the baby spent with mother, an arrangement that affords the opportunity for the child to participate in the facilitys therapeutic child care center. Findings suggest that the earlier a mothers infant resides with her in the treatment setting, the longer her length of stay will be, with an increased opportunity for program completion. In addition, measures of depression were lower and measures of self-esteem were higher for women with their babies than for clients who did not have their infant in the treatment facility. Scores on the Bayley Scales of Infant Development were within normal limits for all infants living with their mothers in treatment.

Newborn evaluations of toxicity and withdrawal related to prenatal cocaine exposure

The literature on prenatal cocaine exposure is unclear whether immediate postpartum effects on the infant are transient, related to either acute toxicity of cocaine, or to a withdrawal effect as cocaine is metabolized, or whether they might persist. This prospective, longitudinal study was designed to test the hypotheses that newborns urine-positive for cocaine metabolites, compared to those exposed but urine-negative, and to nonexposed controls would (1) have poorer neurobehavioral scores (toxicity effect) and (2) worsen or demonstrate less improvement over the first week (withdrawal effect). We approached over 2500 pregnant women designated to deliver at our referral hospital from public health clinics; 85% consented to participate in a longitudinal study. We excluded women <18 years old with major chronic illness and prenatal drug use except cocaine, marijuana, alcohol and tobacco. From positive urine toxicologies or admissions in private, thorough interviews, 154 were identified as prenatal cocaine users; 154 were selected from noncocaine users matched on socioeconomic status (SES), race, parity and location of prenatal care (that related to perinatal risk), for a total sample size of 308. Included in this article are the 155 surviving infants who were full-term, delivered vaginally and were well and available for testing over the first week postpartum. Infant urine specimens were collected, and neurobehavorial testing was performed by certified, blinded examiners using the Neonatal Behavioral Assessment Scale on days 1, 2-4 and 5-7 postpartum. In toxicity analyses, controlling for amount of prenatal drug exposures, only autonomic regulation demonstrated significant overall and cocaine drug group effects. Urine-positive newborns had the poorest scores (i.e., more startles, tremors). However, given that planned comparisons were not significant, these data provided little support for acute toxicity effects. In withdrawal analyses, only one significant change over time varied among exposure groups. Those infants exposed and positive for cocaine metabolites increased their scores on regulation of state on days 2-4 and decreased them on days 5-7 (when withdrawal might be evident). However, their scores on days 5-7 were not significantly lower than their initial scores, nor different from the days 5-7 scores of the exposed negatives or control infants, lending little support for withdrawal effects. Our data support those of other controlled studies in failing to demonstrate devastating early effects of prenatal cocaine exposure. They add to our understanding that effects observed do not appear to be related to acute toxicity nor to cocaine withdrawal. The uncertainty of persistent effects of cocaine exposure warrants long-term follow-up.

Incidence and description of structural brain abnormalities in newborns exposed to cocaine.

OBJECTIVE This study was undertaken to determine whether an increased incidence of structural brain abnormalities could be demonstrated in newborns exposed to cocaine. STUDY DESIGN This study was part of a prospective, longitudinal study of 154 cocaine users matched to 154 control subjects on prenatal risk level, race, parity, and socioeconomic status. Subjects were enrolled prenatally from a rural public health department population or at delivery. Drug exposure was determined by means of repeated, detailed histories and urine screening for drug metabolites. Ultrasonographic examinations were performed within 4 days of birth by experienced technologists and were read by one experienced radiologist, each blinded to drug use history. RESULTS Cranial ultrasonography results were available for 266 infants (134 cocaine-exposed; 132 control). Only 27 infants had ultrasonography results that were not considered normal, and there were no significant differences between groups (17 cocaine-exposed vs 10 control; p = 0.119). Identified abnormalities included choroid plexus cysts, subependymal cysts, mildly dilated ventricles, and a cyst of the third ventricle. CONCLUSIONS The incidence of abnormal cranial ultrasonography results in our cocaine-exposed group was lower than that previously reported in the literature and not significantly different from the control group. In addition, the identified lesions were less severe than previously reported, despite a wide range of cocaine use in our sample, including heavy use.

Executive functioning at ages 5 and 7 years in children with prenatal cocaine exposure.

This prospective longitudinal study evaluated the effect of prenatal cocaine exposure (PCE) on executive functioning in 5- and 7-year-old children. In total, 154 pregnant cocaine users, identified by urine toxicology and structured interviews, were matched to 154 nonusers. Children were assessed by certified masked evaluators, and caregivers were interviewed by experienced staff during home visits. In approximately 90% of the surviving sample tested at ages 5 and 7 years, structural equation modeling demonstrated that an increased head circumference at birth (adjusted for gestation) significantly predicted better performance on executive functioning, and that PCE was indirectly related to executive functioning through its significant negative effect on head circumference at birth. At age 5 years, quality of environment also predicted executive functioning, and the R2 for the total model was 0.24. At 7 years, caregiver functioning predicted quality of environment, which in turn was positively related to executive functioning, and girls had better executive functioning. The total model at age 7 years accounted for 30% of the variance in executive functioning.

Cocaine Suppresses Fetal Immune System

The effects of cocaine are well documented in the CNS; however, recent evidence suggests that cocaine may suppress the immune system. Maternal cocaine use essentially exposes the fetus to a continuous exposure of cocaine. The objective of this study was to investigate the immunomodulatory effects of cocaine and its metabolites on maternal and fetal immune systems. Subjects were recruited from an Investigational Review Board approved protocol, and biologic specimens were collected. For each subject peripheral blood mononuclear cells (PBMCs) were isolated by density gradient. Each PBMC sample was stimulated in separate wells with phytohemagglutinin and phrobol 12-myristate 13-acetate. Samples were radiolabeled and stimulation was measured. Cytokine measurements were made on the serum via ELISA assay techniques. In both the phorbol 12-myrisate 13-acetate and the phytohemagglutinin group, the PBMCs isolated from fetal cord blood in the cocaine-using group had significantly (p < 0.05) decreased responses compared with control subjects. IL 1 and IL 2 concentrations were suppressed in the cocaine-exposed fetal serum compared with controls(p < 0.005 and p < 0.05, respectively). We have shown that in utero cocaine exposure results in a nonspecific suppression of fetal T lymphocyte response. The clinical consequences of prenatal cocaine-induced immunosuppression need to be further explored.

Rural Pregnant Cocaine Users: An in-Depth Sociodemographic Comparison:

As part of a prospective, longitudinal study of the effects of prenatal cocaine use on infant outcome, we enrolled 308 women when they first came in for prenatal care or at delivery, in the case of no prenatal care. The 154 women in the cocaine use group, identified by means of drug history and urine testing, were matched to 154 non-cocaine using controls on race, parity, socioeconomic status, and level of prenatal risk. This report presents a summary of the demographic and drug-use information collected at the time of delivery and the psychosocial data measured at delivery including standardized measures of depression, locus of control, self-esteem, concepts of development, life stress, and social support. Between group comparisons revealed that cocaine users were more likely than non-users to be older, to use other drugs, to begin their drug use at an earlier age, to have more depressive symptoms, to have an external locus of control, to have lower self-esteem, to have a more simplistic understanding of child development, and to have higher positive life event impact scores.

Prenatal Cocaine Exposure: An Examination of Out-of-Home Placement during the First Year of Life

In a longitudinal, prospective study, three groups of infants were defined by placement status through age one: cocaine-exposed infants in out-of-home placement (n=66), cocaine-exposed infants who remained with their biological mother (n=79), and matched (race, socioeconomic status, parity, birth risk) noncocaine-exposed infants who remained with their biological mother (n=141). Of this predominantly African-American, low socioeconomic status, multiparous cohort, 46% of the women who used cocaine prenatally had infants in out-of-home placement at some time during the first year of life. The odds ratio for losing/relinquishing custody, for weeks of cocaine use during pregnancy was 6.0 (1.6, 22.0; 95% CI). More positive life experiences and higher education significantly improved the potential of retaining custody. Depression had a small but significant negative effect on the possibility of maintaining custody. The prenatal and post-partum period is an important time to provide services that encourage substance abuse recovery and associated factors of stability that facilitate an intact mother-infant dyad.

Examiner Masking in Research on the Effects of Prenatal Cocaine Exposure

Masking evaluators is a complex process, calling upon the creativity of scientific investigators and the unrelenting attention of project directors and data collectors. This article reviews research supporting the importance of masking to reduce the effects on outcome of evaluator bias, especially given the evidence of strongly held beliefs about the effects of prenatal cocaine exposure. We discuss the particular difficulty of totally masking examiners who are blind to drug status yet aware of the nature of the study, given an association of drug use and sociodemographic and lifestyle conditions that evaluators may know or observe. Finally we suggest techniques that may be used to facilitate masking. As part of a longitudinal study of the effects of prenatal cocaine exposure, we asked blinded evaluators, after completing the Brazelton Neonatal Behavioral Assessment Scale, to guess whether or not they thought each infant had been cocaine-exposed. The 276 infants were evaluated at birth in a research room without their parents so that the only information available to examiners was what could be observed about the infant. Those infants whom examiners guessed to be cocaine-exposed were significantly smaller by birthweight, were more likely to be black, and had poorer Brazelton performance. The guesses were correct slightly more often than chance (56 percent; p = .050) because of an actual, though weak, relationship between size and performance. In short, the guesses of examiners demonstrated a bias about the relationship of poorer performance and cocaine exposure, supporting the critical importance of our efforts to maintain masking in evaluations.

Cocaine-Exposed Children in Foster/Kinship Care: Effects on Longitudinal Growth Patterns |[dagger]| 1338

Public health concerns about outcomes of prenatally cocaine-exposed infants have often led to foster care placement for these infants. Criteria for foster/kinship care are inconsistent and vary from community to community. Futhermore, the long-term implications of out-of-home placement have not been clearly determined. We report growth data from birth to 36 months for children placed in foster/kinship care vs. those placed with their biological mothers as a subset of a larger longitudinal study of the effects of prenatal cocaine exposure. Women were prospectively enrolled from rural health departments as they came in for prenatal care or arrived at the hospital for delivery. Study subjects, 154 cocaine users (determined by history and urine screenings) and 154 non-users were matched on prenatal risk, race, parity, and SES. Psychosocial and drug histories were taken at the end of each trimester along with child growth measures at 1,6,12,18,24, and 36 months. These evaluations were used to identify the childs primary caretaker (up to 12 mos. of age) and determine the childs longitudinal growth. Maternal drug use was quantified by using detailed drug histories. Three categories of children were analyzed: cocaine-exposed placed in foster/kinship care (N=64), cocaine-exposed placed with biological mother (N=81), and non-exposed placed with biological mother(N=145). There was no significant difference in the neonatal portion of the Hobel risk scale between the groups to suggest higher morbidity at birth for children placed in foster/kinship care. However, there was a significantly higher median amount of prenatal cocaine use by the mothers of the children in out-of-home placement. There were no significant differences in growth parameters for the three groups from birth to six months. After six months there was a significantly lower mean weight for cocaine-exposed infants in foster/kinship care than for cocaine-exposed infants in biological mother care. The difference in weight became greater with time. There also were significantly lower mean height and head circumference for the cocaine-exposed infants in foster/kinship care. The mean weight, height and head circumference for the non-exposed group with their biological mother fell between the two cocaine-exposed groups. All groups had growth parameters within clinically appropriate values. These data suggest that there are long-term implications of out-of-home placement for cocaine-exposed children and that the decision to place these children into foster care should be considered with care.

Congential Abnormalities in Newborns with Fetal Cocaine Exposure |[bull]| 361

Reports in the literature have attributed a variety of structural defects in the newborn to prenatal cocaine exposure. Organ system involvement has included the brain, heart, skeleton, GI and GU tract. This sample was part of a longitudinal study of prenatally identified crack/cocaine users and controls and their offspring, designed to assess the teratogenic effect of cocaine exposure. Women were enrolled prospectively from a rural public health population and were matched on race, parity, prenatal risk, and SES (n=308). Drug use was determined through in-depth histories obtained after each trimester and urine screening for drug metabolites at study entry and delivery. All infants were examined within the first 96 hours of life by experienced examiners blinded to maternal history. Examiners used a modified checklist of 58 major anomalies, all defined in advance. Of the 301 living offspring at birth, 231 were included in the data analyses (119 control; 112 cocaine), excluding infants < 37 weeks gestation, those too sick to be examined in depth by 96 hours, and those missed due to scheduling errors. There were no significant differences between groups in the following measures: nipple width, ear length, palpebral fissure width, inner or outer canthal distance, interpupillary distance, philtrum, clitoral width or length or stretched penile length. The mean number of anomalies per child did not differ by group. The number of children within each group identified with an anomaly did not differ with over 75% of both groups having no identified major anomaly. No infant had more than 4 anomalies identified. The most commonly identified problem was a systolic heart murmur in 28 infants (11% cocaine; 13% control). Of interest was the identification of a single umbilical artery in 7 cocaine and 2 control infants. This study represents one of the first prospective, large-scale, blinded, systematic evaluation for congenital anomalies in cocaine-exposed infants and has failed to identify a consistent pattern of abnormalities. Specifically, in contrast to other reports, we did not find group differences in abnormalities of the skull, heart, skeleton, GI or GU tract.